AMPLIFICATION AND STRATEGIES FOR OPTIMIZING …

AMPLIFICATION AND STRATEGIES FOR

OPTIMIZING COMMUNICATION FOR

HARD-OF-HEARING CHILDREN

Meghan Wisneski, AuD, CCC-A Lisa Yamaguchi AuD, CCC-A

Disclosure

We have the following relevant financial relationship to disclose:

◦ We are Seattle Children’s Hospital Employees

We have no relevant nonfinancial relationship(s) to

disclose.

Obejctives

1. Describe and define “hard-of-hearing” in terms of audiologic classifications.

2. Describe appropriate hearing device options for hard-of-hearing kids.

3. Describe how we verify and validate performance with or without hearing aids.

4. Describe effective communication strategies in various environments.

How does the ear work?

Outer Ear – opening of the ear canal up to the tympanic membrane

Middle Ear – includes the 3 ossicles (middle ear bones)

Inner Ear – includes the cochlea

Auditory nerve

(Washington State DOH)

Types of Hearing Loss

CONDUCTIVE HEARING LOSS means there are problems with the outer or middle parts of the ear. Most times, there is something in the outer or middle ear that blocks the sounds from passing through the structures. Medicine or surgery can sometimes help this type of hearing loss.

SENSORINEURAL HEARING LOSS means there is a

problem with the cochlea (inner ear) or the auditory nerve. This type of hearing loss is permanent. It is not usually fixed by medicine or surgery.

MIXED HEARING LOSS means there is a problem in both

the outer or middle ear and the cochlea.

Classifications of hard-of-hearing

• Mild to Severe Hearing Loss • Unilateral hearing loss (UHL) • Conductive hearing loss (CHL)

Example: Mild to Moderate Sensorineural (SNHL)

Example: Mild to Severe SNHL

Example: Mild to Moderately- Severe, Asymmetric Mixed Hearing Loss (MHL)

Difficulties of Mild to Severe Hearing Loss

Difficulty accessing all speech frequencies ◦ Can lead to speech and/or language delay

Difficulty understanding speech in noise ◦ Can lead to academic or attention issues

Executive functioning or auditory memory

issues (higher level functioning issues)


•Mild to Severe Hearing Loss •Unilateral hearing loss (UHL) •Conductive hearing loss (CHL)

Example: Mild to moderately- severe MHL in right ear

Example: Unilateral profound SNHL

Example: Moderate to Severe CHL

“But my child has one good

hearing ear” –The Importance of Binaural listening

Localization

Listening in Noise

Stimulation of binaural pathways

Effects of unilateral hearing loss on school performance

Children with unilateral hearing loss have greater difficulty… ◦ Localizing where sounds come from

◦ Understanding speech in a noisy classroom

◦ Maintaining attention

More likely to be rated by teachers as having behavior problems

Difficulty with school work, particularly language based subjects such as reading, writing, and spelling.

Kuppler, K., Lewis, M., Evans, A. (2013). A review of unilateral hearing loss and academic

performance: Is it time to reassess traditional dogmata? International Journal of Pediatric Otorhinolaryngology, 77, 617-622.

Justification for Amplification for UHL

“Children with aidable unilateral hearing loss should be considered candidates for amplification in the impaired ear due to evidence for potential developmental and academic delays. Children with unilateral hearing loss are at greater risk than children with normal hearing for speech and language delays and academic difficulties.”

American Academy of Audiology (AAA). (2013). Pediatric amplification Protocol.

Options will be based on your child’s age, anatomy, degree of hearing loss, and listening needs.


• Mild to Severe Hearing Loss • Unilateral hearing loss (UHL) • Conductive hearing loss (CHL)

Why does CHL need its own section?

CHL can often be fluctuating, which adds its own challenges for management

CHL can also have physical barriers to hearing aid fittings that SNHL does not have (ex. otorrhea)

Even though sound detection may return to normal, “functional” hearing may remain impaired

Evidence for Duration of Deficits

Several types of deficits have been measured in early childhood (~0-30 months) related to recurrent OM, including binaural masking level differences, language comprehension/production, and speech in noise testing (Zumach 2010, Zumach 2009, Moore 1991). These deficits seem to resolve by school age.

However, children in these studies were otherwise typically developing, and did not include children with syndromes associated with chronic eustachian tube dysfunction.

Example: Cleft Palate with fluctuating hearing loss

Example (cont.)

Example (cont.)

Hearing Device Options

Amplification: ◦ Conventional hearing aids

◦ Bone conduction devices

◦ CROS systems

Assistive Technology: ◦ Streaming devices

◦ FM systems

Conventional Hearing Aids

How it works: microphone picks up sound, sound is processed in the hearing aid, and sound is delivered to the ear via earmold or slim tip.

Requires a patent ear canal

and pinna.

For any age

Preferred option for bilateral permanent hearing loss


Amplification option for unilateral hearing loss patients

Must have normal anatomy and some degree “usable hearing”

Younger children will usually use earmolds


Conductive hearing loss ◦ Not recommended for acute cases of otitis media (i.e.

hearing loss expected to improve in a matter of weeks)

due to risk of over-amplification

◦ Fittings may be complicated by otorrhea or pain

◦ Important to keep earmold very clean

◦ Important to have an otolaryngologist involved in care when making these recommendations




◦ CROS systems


◦ FM systems

Traditional Bone Conduction Hearing Aids

Good option for children

with abnormal anatomy or

single-sided deafness

Placed on a sweatband or

hard headband

The oscillator and the

microphone are on opposite sides

For any age

Good option to overcome

fluctuations in hearing related to middle ear

dysfunction

Auditory Osseointegrated or Soft Band Processors

Good option for children

with abnormal anatomy or

single-sided deafness

Placed on a softband or

metal headband around the

head, or may be surgically implanted

Microphone and oscillator

are on the same side

For any age




◦ CROS systems


◦ FM systems

CROS Hearing Devices

Contralateral routing of the

signal

The microphone is on the poorer hearing ear and the

signal is wirelessly

transmitted to the good ear.

Requires a pinna and ear canal

For patients older than 5

years of age

Ideally worn without earmolds to avoid occluding

the better ear

Example: Unilateral profound SNHL

Example: Mild to moderately- severe MHL in right ear




◦ CROS systems

Assistive Technology: ◦ FM systems

◦ Streaming devices

FM Systems

Increase the signal-to-noise ratio (SNR).

The FM system consists of a transmitter, microphone, and receiver.

The person speaking will wear the transmitter and the child wears the receiver.

Can be used with a hearing aid or alone.

Can also be in the form of desktop speaker.

Streaming Devices

• Used for connectivity

between hearing aids and

audio devices

• Bluetooth enabled, or can

be used with audio cable

• Some manufacturers have

remote microphone options

• Allows user to listen to

audio input wirelessly

Monitoring Guidelines for Hearing Aid Users

AAA Practice Guidelines (2013) recommend the following

when monitoring children with hearing loss:

• Electroacoustic verification

• Aided audiogram

• Outcome measures • Recommendations for assistive technology

American Academy of Audiology (AAA). (2013). Pediatric amplification: Clinical Practice Guidelines.

Electroacoustic Verification

The Speech Intelligibility Index (SII) is a standardized method of calculating the audibility of a speech signal that can be applied to hearing-aid verification results.

The SII is an acoustic measure, not a behavioral prediction.

This means that the SII represents the audibility of speech, and is not a prediction of speech recognition scores.

UWO PedAMP and AAA 2013

Ensuring Audibility

Example of Electroacoustic Verification and Aided SII

UWO PedAMP (2011)

Electroacoustic Verification- which method to use?

Ching et al (2010): Prescriptive fitting Methods- DSL v4.1 vs. NAL-NL1 Laboratory results vs. real world measures

Real world measures demonstrate:

Preference for soft speech and speech from behind with DSL v4.1

More positive feedback about loudness comfort with NAL

Significant association between reported preference for NAL-NL1 and lesser degrees of hearing loss

Verification (cont.)

So what’s the difference? DSL v4.1 prescribed more gain on average (up to 10 dB)

than NAL-NL1

DSL v4.1 prescribed more low frequency gain than NAL-NL1

This explains why background noise can be more

noticeable or bothersome for some kids

Both methods have shortcomings- NAL-NL1 may not provide audibility for soft speech, but DSL v4.1 may not provide listening comfort in all situations

Verification (cont.)

Scollie, S. (2007) DSL version v5.0: Description and Early Results in Children. Audiology Online, January

15, 2007.

Solution! DSL v5.0

Validation/Outcome Measures

Aided audiogram ◦ Should NOT be used for verification of hearing aid

programming ◦ However, with bone conduction devices may provide some

information

Speech perception testing ◦ Best indicator of performance ◦ Can be completed with single words, sentences, or in noise

to determine many facets of child’s performance

Questionnaires ◦ For younger children, or to get at issues beyond audibility ◦ Rely on parent report for younger children ◦ Allows for screening older children for psycho-social issues

related to hearing loss

Case Study 1

•Aided Testing:

•CID W22 words

•Right: 76%

•Left: 76%

•PBK words

•Right: 92% words,

97% phonemes

•Left: 88% words, 96%

phonemes

•BKB-SIN: 2.2 SNR loss

9 year old boy. Hearing loss first suspected at

age 3, but not confirmed or aided until 6

years old.

Test set-up for bilateral hearing loss

Case Study 2 •Speech-in-Noise Testing:

(Words- CNC test, Sentences-

AzBio)

•Quiet:

•99-100% words,

phonemes, and

sentences

•Noise (+5 SNR) without FM

system

•16% words and 44%

phonemes

•Sentences- 74% correct

•Noise (+5 SNR) with FM

system

•98-100% words,

phonemes, sentences

11 year old girl. Congenital left-sided microtia and

atresia.

Test set-up for unilateral hearing loss

Speech

(toward poor

ear) Noise

(toward

better ear)

Case Study 3

•Aided Testing at age 27

months:

•Ling 6 sound detection-

•RIGHT: /a,i,u,m,s/ at

25 dB HL, /sh/ at 30

dB HL

•LEFT: /a,i,u,m,s,sh/ at

25 dB HL

•Questionnaire: MedEl LittlEars

•Age 8 months- 15/35



27 month old boy. Hearing loss diagnosed at birth,

aided by age 2 months.

Aural Habilitation The goal of aural habilitation (AH) therapy

includes helping a child: ◦ Make sense of sound

◦ Develop language skills through listening

◦ Improve their speech production

Aural Habilitation vs. speech therapy ◦ Both therapies are for children with speech and language

delays or who are at risk for delays

◦ A child without hearing loss may have speech errors that are developmental. They may benefit from speech therapy.

◦ A child who has speech errors related to their hearing loss may benefit from AH.

(Aural Habilitation Therapy. Seattle Children’s Hospital Patient and Family Education, 2013).

Communication Strategies

Good things to do for all kids with hearing loss!


Strategies for home with younger children ◦ Use clear speech ◦ Even rate and do not dramatically slow down ◦ Do not speak LOUDER- this distorts your speech ◦ Create a language rich environment at home ◦ Reduce background noise at home- think about the

unnecessary white noise ◦ Keep your hands away from your face

Enjoy communicating with your child! National Center on Birth Defects and Developmental Disabilities. Early

Intervention: Communication and Language Services for Families of Deaf and Hard-of-Hearing Children. http://www.cdc.gov/ncbddd/hearingloss/freematerials.html

http://www.cdc.gov/ncbddd/hearingloss/freematerials.html


Strategies for school ◦ Explain to teachers the importance of facial cues

and getting child’s attention first

◦ Visual cues (use of white boards or overhead projector)

◦ Environment modification

Preferential seating

Reduce background noise

Soften surfaces

◦ Context- ex. written plan for school day

◦ Have all school personnel aware of hearing loss if they interact with the child

Questions? Thank you!

References American Academy of Audiology (AAA). (2013). Pediatric amplification: Clinical Practice Guidelines. Aural Habilitation Therapy. Seattle Children’s Hospital Patient and Family Education, 2013 Bagatto, MP, Moodie, ST, Malandrino, AC, Richert, FM, Clench, DA & Scollie, SD. (2011). The

University of Western Ontario Pediatric Audiological Monitoring Protocol, Trends in Amplification, 15(1): 57-76.

Ching, T.Y.C., Scollie, S.D., Dillon, H. & Seewald, R.C. (2010). A cross-over, double-blind comparison of the NAL-NL1 and the DSL v4.1 prescriptions for children with mild to moderately severe hearing loss. International Journal of Audiology, 49(Suppl. 1), S4-15.

Moore, D.R. (1991) Binaural masking level differences in children with a history of otitis media. Audiology, 30 (2), 91-101.

National Center on Birth Defects and Developmental Disabilities. Early Intervention: Communication and Language Services for Families of Deaf and Hard-of-Hearing Children. http://www.cdc.gov/ncbddd/hearingloss/freematerials.html

Scollie, S. (2007) DSL version v5.0: Description and Early Results in Children. Audiology Online, January 15, 2007.

Washington State Department of Health EHDDI Program. (2011). Washington State Hearing Loss Helper for Families of Children with Hearing Loss.

Zumach, A. (2009). Otitis media and speech-in-noise recognition in school-aged children. Audiology and Neurootology, 14 (2), 121-9

Zumach, A. (2010). Long-term effects of early-life otitis media on language development. Journal of Speech Language and Hearing Research, 53 (1), 34-43.

www.asha.org/SIG/09/ Kuppler, K., Lewis, M., Evans, A. (2013). A review of unilateral hearing loss and academic

performance: Is it time to reassess traditional dogmata? International Journal of Pediatric Otorhinolaryngology, 77, 617-622.

http://www.cdc.gov/ncbddd/hearingloss/freematerials.html

http://www.asha.org/SIG/09/

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AMPLIFICATION AND STRATEGIES FOR OPTIMIZING …